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Why join insurance panels and go through all the provider enrollment work and effort? For many if not most practices it’s a matter of absolute economic necessity. It’s been estimated that nearly 85% of US citizens are covered by some sort of health care insurance. This can be through their employer or the employer of their spouse or parent, purchased individually or provided by one government program or another. It goes without saying that if you’re going to attract clients to your practice or facility, you will need to get credentialed with the principal commercial health insurers in your area as well as Medicare and the state sponsored Medicaid program. If a practice doesn’t joined these panels, the vast majority of those seeking care will end up seeking it with those providers who do accept their insurance programs.

A second important reason for joining insurance panels is that more and more people are joining and will be joining the ranks of the insured. The most significant driver of this phenomenon is the new healthcare law. While the final framework of the bill is still in doubt, it’s important that you seriously consider those provisions that will likely have a major impact on the patient flows. Current estimates have it that 45 million people here in the US are currently uninsured. The new law provides a opportunity for the majority of them to purchase health insurance through an “exchange” system. These exchanges/ cooperatives, while established and regulated by state governments, will be composed of commercial insurance entities. To enable you to tap into this influx of new clients, you’ll need to be credentialed with those firms participating in the exchange. Another feature of the new health care law that will increase the ranks of the insured is the elimination of the current “preexisting condition” restriction. I think it’s fair to say, because of it’s overwhelming popularity, that regardless of the what the final health care law looks like, this provision will remain in effect. So even if, in it’s final configuration, the health care reform restricts the number of uninsured people added to the rolls of the insured, this provision alone will prevent insurance companies from reducing the number of people currently covered, thereby maintaining current coverage levels.

There are two other broad industry related trends that will increase the need for broad insurance provider enrollment. The first is mental health parity where metal health problems are given the same insurance coverage consideration as biologically related ones. This means, of course, that more people will be seeking help for conditions they didn’t in the past. The second is a recent trend for individuals to select HMO’s over PPO’s. This is a tendency that historically appears during difficult economic times. The net effect of this shift is a reduction in out-of-network benefits which in turn means that a client will think twice before going to a provider not a member of of his or her HMO.

All of these trends make it clear that getting credentialed with the key insurance payors in your market is extremely important to the success of your or your clients practice. And although the provider enrollment process can be a long and difficult one, for most practices it is a necessity.

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As part of our plans to explore provider enrollment issues that lay beyond the current time horizon. The following is Part 3 of a 3 part series of posts on Accountable Care Organizations part of the new healthcare legislation. Credentialing ACO’s is likely to be a complex task. Not only will each individual medical professional within the ACO need to be credentialed with Medicare but the ACO entity itself will need to pass muster as well. The ACO credentialing standards are currently under development by the CMS. An initial proposal was sent to interested parties for review and comment. Among the first to respond was the American Medical Group Association (AMGA). Their comments should be quite reviling since they will likely become the industry trade group that will represent these newly formed ACO group practices.

It might be noted that the AMGA fully supports the ACO initiative in the new health care law and , to my mind at least, had surprisingly few comments or problems with the draft criteria for credentialing ACO groups. Overall they agreed with the framework. There were a couple of issues with which they registered some concern. Their primary problem was with a tiered approach described in the guidelines. The CMS proposed that four classifications for ACO’s be created. Each level would be based upon how close an ACO was to the established standard in terms of client services provided and administrative structure established. The AMGA felt that this approach was unnecessarily complex and suggested that ACO’s be limited to just two levels: Fully developed ACO’s which already possessed the infrastructure necessary to handle the cost and quality requirements and a provisional ACO which could develop the required structure in a three year time frame. It was likely that the CMS suggested the four level approach to make it easier for ACO to get established and qualify for the saving remuneration program.

In addition, the AMGA suggested the requirement that ACO’s carry stop-loss insurance be eliminated, feeling that it was premature in the development of the program. A new set of more stringent privacy standards were proposed. The AMGA felt they should be scaled back to existing federal laws and regulations already on the books. Further, they suggested that the recommended full continuum of care offered by an ACO needed clarification and definition. Finally the standard reporting requirements should apply to private as well as public payors alike.

ACO’s may well become a significant organizational structure in the not too distant future. Its focus on outcome based health services could well assists in reducing healthcare costs. The final look, regulatory requirements and incentive structures are still a work in process, and as we all know the devil is in the details. It’s important that those involved in the provider enrollment issues stay on top of these rules and regulations as they evolve.

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From time to time it’s our plan to explore provider enrollment issues that lay over the current time horizon. Things that, in the future, may impact what we do and how we do it. Issues that providers and others may find of interests or simply a source of speculation around the water cooler. The Affordable Care Act, hate it or love it, creates a number of programs that will significantly impact the load and direction of future credentialing and contracting work. One area that may have such an outcome is provisions which directs the CMS to encourage the creation of what are called Accountable Care Organizations or ACO’s.

What are ACO’s and how do they work? At it’s core, an ACO is a provider group that works on a basis of the cost and quality of care outcomes delivered to its clients, as opposed to the much more prevalent “fee-for-service” approach. An ACO would assume responsibility for the quality, cost, and overall care of a defined population of Medicare clients. It closely resembles the basic Mayo clinic model, with all relevant medical specialties represented within a single group or association. An ACO would be compensated through an a combination of traditional fee-for-service and financial incentives based on the ACO’s abilities to reduce costs, improve quality, and achieve greater patient information integration and transparency.

It must have a management structures that include clinical and administrative systems;

It requires a delineated and detailed processes to promote evidence-based medicine and patient engagement;

It must have an established legal structure allowing it to receive and distribute payments for shared savings;

It must agree to participate in the program for a minimum of three years;

And as sort of an open ended catch-all, An ACO must demonstrate that it has the ability to achieve the objectives set out by the CMS;

Within today broad array of provider organizations, who would be the mostly likely candidates to quickly form ACO’s and take advantage of the associated financial benefits? From small to large, they are:

Virtual Physician Organizations. These are small, independent (often rural) practices that formed loosely organized, virtual organization for reasons of mutual support .

Independent Practice Associations (IPA). These groups were originally formed for the purpose of contracting with insurance payors but have often evolved into more closely knit groups currently engage in a wide range of patient quality improvement programs.

Hospital based physician organizations which are usually composed of a group of providers from a hospital’s medical staff

Integrated Delivery Systems: A company or non-profit which involves the common ownership of hospitals and physician practices and often incorporate an insurance plan. They typically are share electronic health records, feature a team based approach to patient care and in general have the resources to support a cost effective approach to medical care.

Because of their size and integration the last two are most likely to be the models that will be the early adopters. The first three will need considerable technical and organizational support to implement the systems necessary to qualify as an ACO.

Next: ACO’s Part 2 : How they get paid and the impact on provider enrollment issues.

To take a look at the new health care law in all it’s glory click on the link below

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The Patient Protection and Affordable Care Act includes some changes to the provider enrollment process for Medicare. The objective of these changes is to decrease the amount of fraud and abuse in the program. The changes include the following:

Once every 5 years providers must re-certify the accuracy of their enrollment information

If a provider receives a inquiry form a Medicare contractor he/she has 60 calendar days to respond. If a provider doesn’t respond in the allotted time payments may be suspended.

A medicare contractor can perform additional re validations at any time.

When a current owner sells over 5% of his or her ownership in a provider group the changes must be reported withing 30 days.

When a group changes locations, opens a new office or closes one, notification is required

Any Final Adverse Action takes place

Change in Legal Business Name or TIN needs to be reported

When an authorized or delegated official is added or removed.

A change in its bank or bank account

It’s important that you take the time to insure that these changes to your provider enrollment record are complete and accurate. It’s a good idea to appoint someone to specifically handle these issues either within the organization or delegated to an outside group well acquainted with the requirements